“Before death the soul of the ill negotiates with the relatives to enter heaven—if the person recovers it is because the relatives won and chased the spirit back to the body. When a person dies they say the soul roams in the air around the living*.”
Nyath aci koc beu goup: The Dry Skin is Cracking
The floors of the maternity ward are cracked—worn out from the beating sun and time—sand filling in the deep fractures in the concrete like powder or foundation spread over the wrinkles of an old woman’s face; and there is blood too. Those Renk hospital floors hold more stories and history than most places I have stepped. My father, upon seeing a photo, remarked the maternity ward looks like the epicenter of an earthquake. Some of the fissures run up the walls where they meet panels of torn, wire-mesh resembling long, narrow window screens. Everything is broken, falling down.
When I first arrived in the maternity ward I thought the screens a genius idea—they let the ward breathe, they let in light. It didn’t take long to realize my error in thought and opinion. The screens don’t keep the bugs out, or the abuui (dust), and once the rainy season came they made an easy gateway for wind and rain.
Eventually we hung tarps on the outside walls, like plastic curtains we could roll up or down on sticks. But before that I covered up many laboring and malaria- sick women with whatever extra blankets and sheets I could find, working by torchlight as the electricity was often out. I have images stuck in my head of women curled up around newborn babes, colorful, but dirt and blood stained sheets pulled over their heads and tucked under their skin-and-bone bodies. Imagine freezing at 105 degrees F. It was hard during storms to keep the tarps tied down. The wind would whip these plastic sheets of protection up high, stretching them out and away from the walls, letting the sand and cold and rain sneak in before slamming them back down with a loud “bang” making the patients and staff and myself all jump—as though it were a gunshot we had heard.
Giir Amien: The Storm Raises the Dust
One of the women, Afina**, victim to some of the worst storms, was a first time mother diagnosed with pre-eclampsia, a disease causing elevated blood pressure, which if not treated properly can lead to seizures and even death. Most commonly it occurs with first pregnancies and the cure is delivery. Afina was a typical pre-eclamptic patient–swollen, miserable and far from delivery. She stayed in the ward for some days, while the doctor and I managed to keep her blood pressure down, trying to give her body time to ripen on its own. Inducing a first time mother before she is term is challenging and can be dangerous for the baby in the best of circumstances. In the middle of no-where South Sudan, with no way of monitoring pitocin levels and no access to an emergency cesarean, it is an even greater feat, even greater risk. As long as the woman is stable and the baby preterm, we wait. And we wait.
Towards the end of my mission we had many storms. Some of them raged on all night, their strong winds, called mayoum, whipping the sand into a frenzy creating enormous dust clouds. I am certain the clouds held enough sand to fill the sandboxes of America’s children. The khasim was often blinding. It would sting my arms, legs and face when I walked between the wards. The wind drove the sand through the cracks in the walls, under the doorways, through the screens and into our beds, leaving inches of red-grey powder on everything. The midwives would tease me for hiding my face and for attempting the impossible task of keeping the ward dust free. They made comments with ominous overtones. Like the dust and sand, the wind seemed equally unyielding—hot, suffocating. Myths say the two can be a deadly combination, can even dehorn goats.
I have always loved windstorms; have always loved the sound of wind whipping through tree branches, the rattling of windowpanes, the shaking of the house. As a child I found something comforting in being safe and warm in my bed with a new storm brewing. If a cedar tree fell in the woods near our house, as they often did in those wintertime storms, and the power went out…I had no need to worry–we had a fire place and even if we had days of no running water or light, I found that cozy and comforting and exciting too.
Delivering babies in storms isn’t all that comforting, especially under the light of a single headlamp. I liked even less when the midwives made comments about the fateful wind—tonight would be a night for hemorrhages, it’s a poisonous wind, a simoon–tonight the babies will refuse to come, the babies do not like to come out when the wind blows. The babies like to be born in the gentle love of the hawa or the healing harmattan.
I don’t mean to be superstitious, but the midwives generally are right.
Yena bi gok? Whom Shall We Blame?
I worried a lot about Afina. She was quiet and shy and alone—a refugee with no family, no husband, no support. The other women in the ward found her friendly and helped her with food and washing while we waited for labor to begin. The baby’s head remained too high and the cervix too thick to try for induction. So we waited. We used a rebozo to bring the head down and waited. We tried a cervical catheter to help her dilate. We waited. Eventually we tried pitocin and watched and waited. Nothing was working—the little baby would not budge—so we just waited. Finally, after days and days of practicing patience, as my shift ended, her labor began—nice and easy, nothing seemed truly abnormal or out of place, accept that as labor began, so did a storm.
Because of armed conflict, insecurity, politics, no cell phones, lack of resources, the risks to my own safety—for many reasons, that I have been over and over in my head—wishing I could change—I wasn’t at the delivery. I had imagined this mother would labor through the night and hoped Afina would deliver when I arrived early in the morning. Instead, she delivered around 3 am, apparently without any difficulty, but as the storm and midwives predicted, she hemorrhaged. As the storm raged on she continued to bleed, and bleed, and bleed.
In the middle of the night, when the midwives need support, they have to track down one of the national staff doctors—who aren’t always available. I don’t know how to make anyone understand how challenging it is to work in these settings, even under the best circumstances, and this was South Sudan, a war-torn country, with limited resources, limited knowledge, during a storm in the middle of the night.
Post-partum hemorrhage is a leading cause of maternal death. Worldwide more than 1,000 women die daily from childbirth related complications and 24% of women die from post-partum hemorrhage. With proper management, drugs and good nutrition it can be preventable. In the developed world, we have access to all of those things, and if a mother still bleeds too much, we have access to blood transfusions.
“I am as young as the most beautiful wish in my heart – and as old as all the unfulfilled longings in my life…”*
“Mahbrouk,” congratulations, I say to her, in the early hours of the next morning.
Afina peers up at me in the dark room, pale, and quiet; the new baby tucked in at the foot of the bed, a healthy baby girl. I ask the midwives on the morning shift what they knew of the delivery and the blood loss—they report what they know from their handover—easy and quick delivery, hemorrhage, the bleeding seems to have stopped, vitals are low.
In my broken Arabic I ask Afina if she is still bleeding. “Keifa? Nazeef kitheer?”
“Kitheer.” “A lot,” is all she replies. I ask her if the bleeding ever stopped. She shakes her head no.
Around six, after the torrential downpour stopped and the blasting wind calmed, someone sent for the national doctor. He gave her pitocin, plasmion and plenty of IV fluids. The only thing still left to give her is blood. I’m told someone went looking for donors in the nearby refugee camp, but Afina has no biological family. The outlook isn’t good. Time is limited. I ask the staff to check her hemoglobin, it’s about 3.0, way, way too low. She desperately needs blood and I pray that one of the midwives will find someone in the refugee camp to donate.
Afina’s uterus is boggy—not a good sign—I can feel the clots collected inside and glove-up to remove them. Many, many shreds of placenta come with the clots (her placenta must have been very unhealthy). The pieces of placenta have been preventing her uterus from contracting, but with their removal her bleeding seems to stop. I wonder silently if it’s possible that she isn’t bleeding purely because there is no more blood. She is empty, dry and broken like the hospital, like the dry Sudanese earth— If she could just have received blood. If I could just have been present at her delivery.
The staff tell me Afina has hemorrhaged because of the storm, after all it was the kind that dehorns goats. I wish it were that simple. Could it be that simple? I wonder what this mother longed for? What was the bargain Afina made with her ancestors? How hard did they fight to keep her from becoming a ghost in the air around us? What was the wish in her heart?
I am going to become the cracks in the hospital floor, in the walls. I don’t know how to keep out the dust, how to hold back the khasim. I want to become the earth—I get swept up in the dust: Resuscitation—calling the time of death—a small, perfect, sweet baby left all alone—the arrival of community—the washing and wrapping of the body in white cloth. The head and mouth are kept stable with a roll of white, sterile gauze. It goes round and round and round her body. The dust will not stop blowing, filling me, every cell, every atom, every breath. Questions are asked and answered—there is no one to take the baby—she has never been nursed—she has never been held against the breast, the heart of her mother—she has no father—she has no name. The dust keeps filling me—I can’t breathe—I can’t see. Men arrive to transport the body and women receive it and start to wail. They sound like the wind. They mimic the storm.
The women, dressed in ragged and bright colored cloth, create a chorus of lament, howling their grief over Afina. There are maybe twelve of us cramped in the tiny, tarp covered hut—a single bed, a chair, a colorful mat, countless flies and heat that is sickly sweet and overpowering. I hold a newborn tight to my chest. She has a perfect nose and pursed lips. She doesn’t notice when the women start to writhe on the floor in an expression of grief. I on the other hand get caught up in it all and hardly notice when one of the elders asks me to step outside. I am introduced to a short and slim man with an incredible smile and warm, twinkling eyes. He adopted Afina when they were pushed out of Kosti, Sudan to the refugee camp in Renk. He had worried about her being pregnant and alone, without husband or father, and taken Afina under his wing.
He takes my hand, eyes moist with sorrow he in broken English asks me to name the small baby I am still holding. He asks me to give the baby my own name.
How am I supposed to respond? The dust is still filling me—grief for this mother, self-blame, grief for the other lives I have seen slip away, grief for the conditions of these people. The cracks seem to be growing larger. My heart cannot bear to break anymore.
“Nassim,” I say to him. It’s the name my staff gave me.
Nassim. The gentle breeze.
*common sayings in s. sudan
**name have been changed to protect the privacy of those involved, but I chose names that to me have similar meaning. Afina means “of the earth.”