The Hospital

Someone asked me the other night why I couldn’t go back to the hospital if the heat, humidity, dust, mud of our living “compound” got too much for me sometimes. Which made me aware that I should probably give you a basic description of what the hospital is like.

The short answer is that it may not be like anything you have ever associated with the word (unless you’ve seen hospitals in poor countries – it’s exactly like many of those). The environment inside is not more agreeable than our hot, muddy, fly-beset compound, but considerably less so. (But this makes sense, right? Wherever it is you live, would you rather be in your house – or at a hospital?) It is not air conditioned; it is not modern; it is not sparkling. What it is is a collection of five or six long, painted cinderblock buildings with screened but not glassed window openings, most of them set up as open wards full of dented iron bedsteads supplied with waterproof (think: not breathable) mattresses, each maybe two or two and a half feet from its neighbor. Or, at least, that’s how the original part is. There is also an extension made of four industrial-size rubberized tents (think, again: not breathable).

It is a government hospital, and I believe (?) that outpatient services are available to everyone in the community, provided by the state. However, the large majority of the inpatient hospital serves two populations: pregnant (or peripartum) women, and children. This part of the hospital is effectively run by MSF, and all the staff – “expat” and “national” – are MSF employees.

There are pregnancies all the time, of course, but at least a couple of rhythms govern the pediatric caseload: The “malnutrition season” and the “malaria season.” You can probably figure the latter one out for yourselves: it’s the rainy season now, and, as I have learned even at my New York apartment basically every time it rains and the temperature is above maybe 40 degrees – rain=standing water=mosquitoes. The last term in the equation, here, being “mosquitoes=malaria.”

The malnutrition season is a little more puzzling. On the face of it, it has to do with the rains – by the end of the dry season, not much has been growing for a while, so subsistence farmers run out of food and their kids get malnutrition, up until it has been raining long enough for new, harvestable food to grow. The thing that makes it a little more puzzling is the fact that South Sudan is for the most part a pretty fertile, well-watered place. So you’d think you might be able to put up a sizeable surplus every rainy season, to last through the dry. (I should say that I know absolutely nothing about farming, especially of the subsistence variety.) Possible explanations that I’ve heard or thought of for why this is not so: The Dinka are VERY identified with cattle herding and see farming as a bit beneath them, but the money economy has given them incentives to concentrate their cattle near market areas, leaving fewer in the hinterlands to feed the people there. The money economy (and perhaps food aid??) has, in general, distorted incentives, inducing people to rely on store-bought food even as their access to the money needed to buy it is highly variable. Civil unrest/war has disturbed agricultural patterns. Storing a surplus is not easy in a very hot, very poor country. The population is larger than it used to be. The climate is changing. When it rains, it rains too much, and you can’t grow food in a swamp.

Whatever the explanation(s), there is apparently a spike in pediatric malnutrition admissions that continues well into the rainy season, and a spike in malaria admissions that grows as that same rainy season progresses. Which means that we are in the place where both conditions are spiking – right about now.

I tell you all this to underline that the pediatric wards are FULL (as, in fact, is the maternity ward). All the beds are full, and there may sometimes be two or even three kids per bed, with others on mattresses on the floor.  So, to continue outlining my picture of the physical space we work in – imagine these buildings and tents, filled with people, with either an occasional fan or nothing for ventilation, with patients coming in and out after walking over red earth that is, variably, mud or dust, when the outside temperature is often in the 90s (the 100s in the dry season). The wards are inevitably dusty, grimy, sweaty, smelly places, despite the fact that the staff seems to do a great job of keeping them basically clean. Happily, it seems like the plumbing, though rudimentary, works: though I won’t say there is never the tang of urine in the air (!), the key principle of not pooping where you eat (or drink) seems to hold.

But, you know – at bottom, though it isn’t the sort of squeaky-clean place we associate with the word in the States (well – ha! – sometimes), it seems to me to basically work. I can’t imagine it is fun, fun, fun to be there – but, again, have you EVER seen a hospital (aside maybe from the out-of-pocket vanity suites that all big NY hospitals now seem to have) that was? Basically clean, basically orderly, sterile when it needs to be. We could, in fact, probably afford to be a little less obsessed with sterility in the States, with little cost to patients and significant savings of money.

So, no – it is not a place I would go to escape the heat and dust of the compound! But it isn’t badly run, and once you get over the shock of a hospital looking “like that,” you see that, in lots of important ways, it gets the job done.